Partners create a healthcare system to meet the needs of uninsured during H1N1 surge

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In Brief

Concerned about the inability of large numbers of uninsured people to access care early in the 2009 H1N1 pandemic, an Oregon regional preparedness organization partnered with public health, care providers, and community organizations to create a flu-related care delivery system exclusively for uninsured and low-income people. By offering a nurse triage call center, over-the-phone antiviral prescriptions, and clinic appointments, the Access to Influenza Care project served 63 people and demonstrated the ability of many different partners to address healthcare system gaps during an emergency.


During a disaster, the strain on providers to care for the surge of sick and/or worried people can narrow access to care for people with no health insurance or limited financial resources. Such was the case when the H1N1 virus emerged in spring 2009. In the Portland, Oregon, metro area, several local health directors asked the Northwest Oregon Health Preparedness Organization (a collaboration of public and private healthcare partners whose goal is to prepare and respond effectively and efficiently to serious large-scale health emergencies that cross institutional and jurisdictional lines) to develop a healthcare system that could operate alongside the existing system and serve uninsured people in need of medical care or advice.

Specific issues
  • During the early months of the H1N1 pandemic, clinics were inundated with people seeking care, and people with no medical home and no insurance experienced difficulties in finding clinics where they could receive care. Project planners were concerned that uninsured people would turn to hospital emergency departments for flu-related care.
  • Safety net clinics, sliding scale clinics, and Federally Qualified Health Centers (FQHCs) were unable to serve many uninsured people. Such clinics often operate at full capacity during non-emergency times, and the scarcity of supplies and available staff during H1N1 prevented many of them from seeing new patients.
The practice

The Northwest Oregon Health Preparedness Organization developed a three-tier system comprising phone-based medical evaluation, antiviral dispensing, and donated clinic visits to meet the influenza-related healthcare needs of low-income and uninsured people.

The Access to Influenza Care project was developed during the summer and early fall of 2009 and implemented in October. The project was intended to address a need that safety net clinics were not able to meet. The organization involved the clinics during the planning process to understand their experiences and determine how best to provide H1N1 care. The project itself involved four avenues of care:

  • A state H1N1 call center screened eligible callers for referral to phone-based evaluation. Oregon's H1N1 call center was operated by 211info, a centralized clearinghouse for social service needs, and the organization partnered with staff to connect callers to a nurse triage call center based on eligibility criteria. Eligible individuals had to 1) be residents of Clackamas, Columbia, Multnomah, or Washington counties; 2) be seeking care; 3) be low-income (ie, at or below 200% of the federal poverty level); 4) lack a medical home; and 5) lack health insurance.
  • Registered nurses evaluated patients over the phone, referring them to self-care at home, antiviral treatment, an in-person clinic appointment, or immediate emergency care. Nurses used a triage protocol developed specifically for the project by the Tri-County Health Officer Program.
  • Nurses prescribed antivirals to patients over the phone. The project prescribed antivirals obtained from the Strategic National Stockpile to patients who were eligible for and required treatment. Patients could pick up their antivirals at 1 of 7 county distribution sites established by the project. Children required an in-person clinic visit to receive an antiviral prescription, due to dosing concerns.
  • Clinic appointments were set up for patients who indicated a need to be seen in person. Area hospitals and clinics donated appointments to the project, with two hospital systems offering to donate 500 appointments per month for up to 5 months. The organization created a spreadsheet to ensure that patient flow for these donated appointments was tracked accurately.
What made this practice possible?
  • Funding from CDC and cooperation from local partners gave this project a fairly broad reach and ensured that all components could operate smoothly. The organization added the project's scope of work to an existing CDC-funded pandemic influenza program, and health systems and community partners donated an array of services, such as marketing materials and clinic appointments for uninsured people.
  • Partnership with the Coalition of Community Health Clinics gave insight into the needs and capacity of safety net clinics, and also resulted in community clinics publicizing the Access to Influenza Care project to their communities and clientele.
  • Discussions around policy issues allowed the project to integrate issues like poverty level, underlying medical conditions, potential need for follow-up care, and health information privacy into protocols for the project.
  • CareOregon's donation of nursing staff and other resources permitted the establishment of a nurse triage call center. The Medicaid-managed HMO also provided telephones and computers, a nurse liaison/consultant, and liability coverage that was shared between the counties and CareOregon. Nurses provided triage under standing orders issued by a Tri-County Health Officer physician. CareOregon nurses were eventually replaced with local Medical Reserve Corps volunteers.
  • Partnerships with safety net clinics, county public health departments, and local emergency management agencies allowed the project to move and track antivirals, as well as maintain the ability to distribute them at multiple sites.
  • Hospitals, health systems, and safety net clinics donated influenza care treatment for patients evaluated through this project. Project Access Now, a nonprofit organization addressing charity healthcare, provided the organization with hospital contacts and guidance on fairness and policy issues.
  • The project served 63 low-income, uninsured individuals in need of influenza care. Although the project did not serve as many people as expected, it provided services to people who would not otherwise have been able to access healthcare.
  • Half of the callers required the use of a donated clinic visit. Self-care was advised for 22% of callers, 21% received a prescription for antivirals, and four people required emergency care. The majority of callers (75%) had a complicating condition in addition to influenza symptoms.
  • Phone prescriptions for antivirals reduced the number of donated clinic visits that were used and may have ensured that people received medication within the appropriate timeframe.
  • Sixteen healthcare systems across four counties donated a total of 2,000 clinic visits each month for 5 months. The project reported that regional health systems and providers enjoyed the friendly competition to donate appointments.
  • The project provided healthcare services as designed. It demonstrated the ability of public health agencies, community partners, and healthcare systems to address issues of surge and access to healthcare in a coordinated manner.

The Access to Influenza Care project was developed fairly quickly to address an immediate need. Planners identified several areas that might benefit from consideration should any aspect of this project be implemented in the future. Factors or ideas for future operations include:

  • Establishing a semi-permanent host or infrastructure in which to house and operate a phone-based nurse triage system
  • Formalizing commitment from healthcare systems for clinic appointment donations in future health emergencies
  • Fostering agreement from community partners, public health, and healthcare providers on policy issues, such as how to address providing influenza-related services to a patient who is found to require more extensive care
  • Developing agreements between various levels of government on implementation, operation, and funding related to healthcare access during emergencies

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